Referral Form

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If you would like to discuss this referral prior to submitting the form please contact Ann Bradwell (Manager) - ann@homestartstirling.org.uk

Name of Parent to be Supported *

Address & Postcode *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Layout

Telephone Number

Mobile Number *

Referred by:

Referrer

Referrers Name: *

Role: *

Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email: *

GP Practice *

GP Tel: *

Address of GP Practice *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please √ all that apply to this family *

Family member in prison
Forces
Refugee/asylum seeker
1 or more parents employed
Debt-Finances
Speech & Language issues
Lone Parent
Substance misuse
Domestic Abuse
Disabilities
Teenage Pregnancy
Mental health issues
Peri-mental Health
Mutliple Births

Are there any Health and Safety issues that we need to consider when placing a volunteer with this family: *

Please add any background information that you think we would find useful including GIRFEC information – any additional forms can be emailed to ann@homestartstirling.org.uk *

Please provide a summary of the support required by the family *

Family Needs

Select all that apply *

Managing child's behaviour
Being involved in the child(ren)'s development
Coping with own physical health
Coping with own mental health
Coping with feeling isolated
Parent's self-esteem
Coping with child's physical health
Coping with child's mental health
Managing the household budget
The day-to-day running of the house
Stress caused by conflict in the family
Coping with multiple birth/multiple children under 5
Use of services
Parents own learning needs

Other (please describe)

Agencies currently supporting the family

Are there are any agencies currently supporting the family? *

Agency 1

Name of Person *

Is there a second agency supporting the family? *

Name of Agency *

Email *

Agency 2

Name of Person from Second Agency *

Is there a third agency supporting the family? *

Name of Second Agency *

Second Agency Email *

Agency 3

Name of Person from Third Agency *

Is there a fourth agency supporting the family? *

Name of Third Agency *

Third Agency Email *

Agency 4

Name of Person from Fourth Agency *

Name of Fourth Agency *

Fourth Agency Email *

Details of Children

Please record all dependent* children in the household - eldest first (please complete those boxes which apply to any of the children).

First Child (eldest first)

Eldest Child

Gender *

Immigration Status *

Ethnic group *

Date of Birth *

Considered to be disabled by main carer? *

Child care / protection plan *

Is there a second child? *

Second Child

Second Child Gender *

Second Child Immigration Status *

Second Child Ethnic group *

Second Child Date of Birth *

Is the second child considered to be disabled by main carer? *

Second Child - Child care / protection plan *

Is there a third child? *

Third Child

Third Child Gender *

Third Child Immigration Status *

Third Child Ethnic group *

Third Child Date of Birth *

Is the third child considered to be disabled by main carer? *

Third Child - Child care / protection plan *

Is there a fourth child? *

Fourth Child

Fourth Child Gender *

Fourth Child Immigration Status *

Fourth Child Ethnic group *

Fourth Child Date of Birth *

Is the fourth child considered to be disabled by main carer? *

Fourth Child - Child care / protection plan *

Is there a fifth child? *

Fifth Child

Fifth Child Gender *

Fifth Child Immigration Status *

Fifth Child Ethnic group *

Fifth Child Date of Birth *

Is the fifth child considered to be disabled by main carer? *

Fifth Child - Child care / protection plan *

Is there a sixth child? *

Sixth Child

Sixth Child Gender *

Sixth Child Immigration Status *

Sixth Child Ethnic group *

Sixth Child Date of Birth *

Is the sixth child considered to be disabled by main carer? *

Sixth Child - Child care / protection plan *

Details of Members of the household with responsibilities for caring for the children

(Please ensure all details are completed)

Main Carer

Main Carer Name *

Gender *

Immigration Status *

Main Carer Ethnic group *

Relationship to child/children (eg mother) *

Date of Birth *

Consider themselves to be disabled? *

Is there a Partner living in the household? *

Partner

Name of partner living in house *

Partners Gender *

Partners Immigration Status *

Partner Ethnic group *

Partners relationship to child/children *

Partners Date of Birth *

Does the Partner consider themselves to be disabled? *

Is there another main carer? *

Other Main Carer

Name of other main carer *

Other main carers gender *

Other main carers immigration status *

Other Main Carer Ethnic group *

Other main carers relationship to child/children *

Other Main Carers Date of Birth *

Does the other main carer consider themselves to be disabled? *

PRIVACY NOTICE and CONSENT STATEMENT

In the course of the scheme and Home-Start UK (“we”/”us”) providing support and friendship to your family and monitoring and evaluating your needs, we collect and hold certain personal information about you. We will only do so with your explicit consent and in accordance with all applicable data protection legislation, including the General Data Protection Regulation.

Information collected

The personal information collected by us will be limited to that which is essential to allow us to provide the support you require and deserve. This will include:

Names, genders, addresses, telephone numbers and e-mail addresses.
Employment, immigration statuses, disabilities (such as physical or learning disabilities) and racial/ethnic origins.
Data concerning health and sex life (such as substance abuse, domestic abuse, mental health, depression and pregnancy).
Details of any ancillary support servicesw/agencies being used by the family (such as family GP, health advisors, social workers, mother & baby clinics, children’s centres, CAMHS, CPN/mental health, debt counselling, legal support, employment, housing support, education and dentistry).
In the case of children, additional information as to whether the child is subject to assessment needs (such as CAF/UNOCINI) or a child care/protection plan, or is a child in need.

We may also collect information from any individual/agency that has referred your family to us.

How we will use your personal information and who it will be shared with

Internal

Our volunteers discuss your support with the appropriate organiser/co-ordinators, who in turn discuss your support with their line managers. Discussions take place in a confidential setting, for the purposes of supervision and to ensure the best possible support to your family. Volunteers meeting together for peer support do not share information that may identify, or breach the confidentiality of your family.

All information provided to our board of trustees for the purpose of assessing the level of referrals, local trends or case studies shall be anonymised.

External

We will, on an anonymised basis, use your personal information to demonstrate the impact of our services. Any case study infroamtion shared will always be on anonymised basis unless we have further explicit consent from you.

We will inform funders and your health visitor (and other agencies involved with your family) that you have sought support from us (including the nature and level of such support) and provide them with relevant information. In the event your family has been referred to us, we shall share the same information with your referrer (this will include any changes to the support and informing the referrer when the support comes to an end).

We may share your personal information with Home-Start UK for the specific purposes of statistical analysis and the promotion of our work nationally as well as any reporting requirements for funders who support the network on a national level. This will be on a pseudo-anonymised basis (meaning that we will take steps to limit the ability to for your personal information to be identified. This will normally include the anonymization of names and full addresses).

We may share your personal information with our external auditors for quality auditing purposes but only in the presence of your organiser/co-ordinator and only after the auditors have providing us with all necessary written undertakings to preserve the security and confidentiality of your information.

We will share personal information with law enforcement or other authorities if required by applicable law (including, in line with our Safeguarding and Promoting the Welfare of Children/Safeguarding Adults at risks policies, where there are concerns about the safety or wellbeing of a child or adult at risk and it is considered necessary for their welfare and protection).

We will not share your personal information with any other third party without first obtaining your explicit consent.

How long your personal information will be kept

We will keep your personal information after we have finished providing our support to respond to any questions, complaints or claims made by you or on your behalf, to show that we treated you fairly and/or to keep records required by law. We will not keep the information for longer than necessary. We keep different types of information for different lengths of time (further details can be found in our Information Governance Policy which is available on request).

Keeping your personal information secure

We have appropriate security measures in place to prevent your information from being accidentally lost, or used or accessed in an unauthorised way. We limit access to your personal information to those who have a genuine need to know it. Those processing your information will do so only in an authorised manner and are subject to a duty of confidentiality. We also have procedures in place to deal with any suspected data security breach. We will notify you and any applicable regulator of a suspected data security breach where we are legally required to do so.

Your Rights

You have a number of important rights which you may exercise in relation to your personal information free of charge. In summary, those include rights to:

access your personal information and to certain other supplementary information that this Privacy Notice is already designed to address;
require us to correct any mistakes in your information which we hold;
require the erasure of personal information concerning you in certain situations;
receive the personal information concerning you which you have provided to us, in a structured, commonly used and machine-readable format and have the right to transmit those data to a third party in certain situations;
object at any time to the processing of personal information concerning you for direct marketing
object to decisions being taken by automated means which produce legal effects concerning you or similarly significantly affect you
object in certain other situations to our continued processing of your personal information; and
otherwise restrict our processing of your personal information in certain circumstances.

For further information on each of these rights, including the circumstances in which they apply, visit the Information Commissioner’s Office (“ICO”) website at https://ico.org.uk/for-the-public/.

If you would like to exercise any of the rights, please email, call or write to us using the details in ‘How to contact us’ below, let us have enough information to identify you, let us have proof of your identity and address, and let us know the information to which your request relates.

How to complain

Please report any complaint to the details set out in ‘How to contact us’ below. We hope we can resolve any query or concern you raise about our use of your information. You also have the right to lodge a complaint with the ICO who may be contacted at https://ico.org.uk/concerns/ or telephone: 0303 123 1113.

How to contact us

Please contact us if you have any questions about this Privacy Notice or the information we hold about you as detailed below:

CONSENT *

I confirm I have consent from the family to share their personal information with Home-Start Stirling

Please note that by signing this form you are advising Home-Start Stirling that you have consent from the family to share their personal information with Home-Start Stirling. You have also informed the family that their personal information will be retained within the current Data Protection guidelines. (For further information please see Home-Start Stirling’s Privacy Statement. Information regarding our Privacy Statement will be shared fully with the family at the initial visit). We are unable to process your referral until we have received this form. We aim to contact the family within 2 weeks of receiving the referral. If we feel this will be later than 2 weeks we will notify you at the referral stage. We will remain in touch while supporting this family and will contact you when the support ends. If you have any issues or concerns about the referral process or the support for the family please contact Ann (Manager).

Consent

Referrers name *

Referral Date *

Contact Us

HOME-START STIRLING
Registered Office

Kildean Business & Enterprise Hub
146 Drip Road
Raploch
Stirling
FK8 1RW

Telephone: +44 (0)1786 498466
Email: admin@homestartstirling.org.uk

Company Number: SC276401
Scottish Charity Number: SCO23619

Find Us

Our office is located in the heart of Stirling with easy access via road and rail network links.

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